A nurse is assessing the level of consciousness of a patient who has sustained a head injury in a motor vehicle accident. The nurse notes that the patient appears drowsy but the nurse is able to wake the patient by gently shaking and calling the patient by name. What level of consciousness would the nurse document?

A. Every four hours:

Turning a client every four hours may not be frequent enough to prevent pressure ulcers, especially in individuals with physical limitations or recent surgical procedures.

B. Every hour:

Turning a client every hour might be too frequent for some patients, and it may disrupt their rest and sleep. The optimal frequency depends on the client's condition.

C. Every shift:

Turning a client every shift (which typically spans 8-12 hours) may not provide adequate prevention for pressure ulcers, especially if the client has limited mobility.

D. Every two hours:

Turning a client every two hours is a common practice to prevent pressure ulcers. This interval helps redistribute pressure on vulnerable areas, improving blood circulation and reducing the risk of skin breakdown.

A. Use standard precautions in caring for all clients:

Standard precautions involve applying infection prevention practices to all clients, regardless of their known or suspected infectious status. This includes hand hygiene, use of personal protective equipment (PPE), and safe injection practices. Standard precautions are designed to prevent the transmission of microorganisms and break the chain of infection.

B. Place all post-surgical clients in contact isolation:

Contact isolation is typically used for clients with known or suspected infections that can be spread through direct or indirect contact. Placing all post-surgical clients in contact isolation may not be necessary unless there is evidence of a specific infectious condition.

C. Order IV antibiotics for all clients with sacral pressure wounds:

Ordering antibiotics is a specific treatment for bacterial infections but does not address the broader approach of breaking the chain of infection for all clients.

D. Limit visitations to 2 people a day for each client:

While limiting visitations can reduce the risk of introducing infections, it does not address the nurse's direct care practices and adherence to infection prevention measures.